Stepwise interventions for improving hand hygiene compliance in a level 3 academic neonatal intensive care unit in north India.

OBJECTIVE: We evaluated effect of sequentially introducing four WHO-recommended interventions to promote hand-hygiene compliance in tertiary-care NICU. STUDY DESIGN: Four dedicated research nurses directly observed doctors and nurses to record success in hand-hygiene opportunities at randomly selected NICU beds and randomly sampled time-slots in four phases (of 4-weeks each): I-Baseline, II-Self-directed learning; III-Participatory learning; IV-Closed-Circuit Television (CCTV); and V-CCTV-plus (with feedback). FINDINGS: Hand-hygiene compliance changed from 61.8% (baseline) to 77% (end) with overall relative change: 24.6% (95% CI 18, 32; p value= 0.003); compared with preceding phase, relative changes of 21% (15, 28; <0.001), 4% (0, 8; 0.008), -10% (-13, -6; <0.001), and 10% (5, 15; <0.001) during phases II, III, IV, and V, respectively were observed. Rise in hand-hygiene compliance was higher for after-WHO-moments (12.7%; upto 2.5-folds for moment 5, <0.001) compared to before-WHO-moments (5.2%). Educational interventions, feedback and monitoring WHO moments can improve hand-hygiene compliance significantly among health-care providers in NICU.

Aqueous chlorhexidine 1% versus 2% for neonatal skin antisepsis: a randomised non-inferiority trial.

OBJECTIVE: To evaluate whether 1% aqueous chlorhexidine gluconate (CHG) when compared with 2% aqueous chlorhexidine gluconate is non-inferior for neonatal skin antisepsis. DESIGN: Parallel, blinded, non-inferiority randomised trial. SETTING: Level III, academic, neonatal intensive care unit. PATIENTS: Infants born at 260/7 to 426/7 weeks of gestation from June 2019 to December 2019. INTERVENTIONS: Participants were randomised to skin antisepsis by either 1% aqueous CHG or 2% aqueous CHG. MAIN OUTCOME MEASURES: The primary outcome was the proportion of negative skin swab cultures after skin antisepsis. Secondary outcomes were local skin reactions at 0, 6, 12 and 24 hours and plasma chlorhexidine levels in a subset of the study population. RESULTS: A total of 308 neonates with a median gestation age of 34 (31-37) weeks and mean birth weight of 2029 g were randomised on 685 occasions (1% CHG: n=341; 2% CHG: n=344). 93.0% of the post-antisepsis skin swabs were sterile in 1% CHG group compared with 95.6% of the swabs in the 2% CHG group (risk difference -2.7%, 95% CI -6.2% to +0.8%). The lower bound of 95% CI crossed the pre-specified absolute non-inferiority limit of 5%. Neonates developed mild dermatitis on 16 (2.3%) occasions. There was no significant difference in median plasma CHG levels in the two groups, 19.6 (12.5-36.4) and 12.6 (8.7-26.6) ng/mL, respectively. CONCLUSIONS: Application of 1% aqueous CHG was not shown to be non-inferior to 2% chlorhexidine aqueous for skin antisepsis in neonates. There were no severe skin-related adverse events in either of the two groups. TRIAL REGISTRATION NUMBER: CTRI/2019/06/019822; (http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=33453&EncHid=&userName=CTRI/2019/06/019822).

Dissemination of Best Practices in Preterm Care Through a Novel Mobile Phone-Based Interactive e-Learning Platform.

OBJECTIVE: To describe an innovative interactive e-learning method to disseminate knowledge to larger group of participants over a wide geographical area. METHODS: The course material included standard training tool "Best Practices in Preterm Care," hosted on Telegram, a cloud-based instant messaging platform. The participants were enrolled in the group created on Telegram by the facilitators and included in-service nurses from India, Bhutan, Bangladesh, and UAE. They were mentored by 62 facilitators over 10 wk. Content of each module was loaded every week on two specific days. Mentors specified for that week facilitated learning through discussions. There was a live session every week to address any additional queries and to summarize the key messages of the week. Each week ended with weekly assessments through quiz. RESULTS: In this course, 4623 nursing professionals from India and Southeast Asian Region involved in providing neonatal care, participated. There were 9939 posts with an average of 126 posts per day. Majority of the participants felt that the topics were relevant (~95%) and they were comfortable in asking questions and could clarify their doubts (~90%). Majority rated their overall experience as very good to excellent (~98%). CONCLUSIONS: Interactive e-learning using the current approach if channelized optimally seems to be acceptable and feasible method to reach wide geographical area. This, however, needs local champions ready to mentor their own health professionals with context-specific guidance.

Pharmacokinetics-Based Optimization of Phototherapy in Neonates Undergoing Treatment for Hyperbilirubinemia.

Introduction: Neonatal jaundice results from combined effects of both increased production of bilirubin and decreased hepatic excretory capacity in neonates. Since its discovery, phototherapy is the most widespread treatment used in neonatal jaundice. In this work, we try to search for a relationship between exposure to phototherapy and decrease in serum bilirubin (linearity vs proportionality). Methods:The present research was non-randomized prospective study conducted in the Neonatal Intensive Care Unit (NICU), Department of Paediatrics, AIIMS, New Delhi, and the Department of Pharmacology, AIIMS, New Delhi, India. Subjects were recruited from neonates admitted in NICU AIIMS, which meets our selection criteria. Infants were given a low dose of either phototherapy continuously or phototherapy for the first six hours and a double dose of phototherapy for the next six hours. Samples were collected before the beginning of the study (0 hours) and then at six and 12 hours. Bilirubin concentration was measured using HPLC and (LC-MS/MS). Results and conclusion:The percentage of reduction during the 6-12-hour interval was compared with that during the 0-6-hour interval if all experimental conditions were kept unchanged. A relationship curve between percentage of reduction and irradiance was created based on the percentage of reduction in serum bilirubin during the 0-6-hour and 0-12-hour intervals. The present study suggests that the relationship between efficacy, as measured by percentage of reduction in serum bilirubin, and irradiance is unlikely to be linear. Collected data are insufficient to clearly distinguish between proportionality and saturation point, considering that the results may be possible with both of these hypotheses.

Validation of visual estimation of neonatal jaundice in low-income and middle-income countries: a multicentre observational cohort study.

OBJECTIVE: Determine the sensitivity and specificity of neonatal jaundice visual estimation by primary healthcare workers (PHWs) and physicians as predictors of hyperbilirubinaemia. DESIGN: Multicentre observational cohort study. SETTING: Hospitals in Chandigarh and Delhi, India; Dhaka, Bangladesh; Durban, South Africa; Kumasi, Ghana; La Paz, Bolivia. PARTICIPANTS: Neonates aged 1-20 days (n=2642) who presented to hospitals for evaluation of acute illness. Infants referred for any reason from another health facility or those needing immediate cardiopulmonary resuscitation were excluded. OUTCOME MEASURES: Infants were evaluated for distribution (head, trunk, distal extremities) and degree (mild, moderate, severe) of jaundice by PHWs and physicians. Serum bilirubin level was determined for infants with jaundice, and analyses of sensitivity and specificity of visual estimations of jaundice used bilirubin thresholds of >260 µmol/L (need for phototherapy) and >340 µmol/L (need for emergency intervention in at-risk and preterm babies). RESULTS: 1241 (47.0%) neonates had jaundice. High sensitivity for detecting neonates with serum bilirubin >340 µmol/L was found for 'any jaundice of the distal extremities (palms or soles) OR deep jaundice of the trunk or head' for both PHWs (89%-100%) and physicians (81%-100%) across study sites; specificity was more variable. 'Any jaundice of the distal extremities' identified by PHWs and physicians had sensitivity of 71%-100% and specificity of 55%-95%, excluding La Paz. For the bilirubin threshold >260 µmol/L, 'any jaundice of the distal extremities OR deep jaundice of the trunk or head' had the highest sensitivity across sites (PHWs: 58%-93%, physicians: 55%-98%). CONCLUSIONS: In settings where serum bilirubin cannot be measured, neonates with any jaundice on the distal extremities should be referred to a hospital for evaluation and management, where delays in serum bilirubin measurement and appropriate treatment are anticipated following referral, the higher sensitivity sign, any jaundice on the distal extremities or deep jaundice of the trunk or head, may be preferred.

Reliability of transcutaneous bilirubinometry from shielded skin in neonates receiving phototherapy: a prospective cohort study.

OBJECTIVE: To determine the agreement between transcutaneous bilirubin (TcB) measured from shielded skin and serum total bilirubin (STB) in infants (34 to 41 weeks of gestation) with hyperbilirubinemia receiving phototherapy (PT). STUDY DESIGN: In this prospective cohort study, we shielded a small area of skin on sternum using a commercial photo-opaque patch (BilEclipseTM, Philips Respironics, Murrysville, PA, USA). The TcB from the shielded skin (TcBs) and STB were measured at four time points-before initiation, 12 and 24 h during and once after (12 h) cessation of PT. TcB was measured using multiwavelength transcutaneous bilirubinometer (BiliChek, Philips Children's Medical Ventures, Monroeville, PA, USA). The STB was measured in triplicate by spectrophotometry (Apel BR 5100, APEL, Japan). Bland and Altman plots were drawn to determine agreement between the TcBs and STB. RESULTS: The gestation and birth weight of enrolled neonates were 37.0 (1.0) weeks and 2750 (458) g, respectively. The age at initiation and duration of PT were 75 (27 to 312) and 25.3 (4.4) h, respectively. Bland and Altman plot showed poor agreement between TcBs and STB at all time points. The gradient (median, range) between TcBs and STB at 0, 12, 24 h and 12 h after cessation of PT were -0.2 (-4.9 to 3.5), 1.4 (-4.7 to 4.0), 1.5 (-3.8 to 9.4) and 2 (-2.9 to 5.8) mg dl-1. The proportions of TcBs values outside ±1.5 mg dl-1 of STB ranged from 47 to 64% at four time points. CONCLUSION: TcBs does not appear to be reliable for estimating serum bilirubin in late preterm and term neonates receiving PT.

Comparison of conventional, immunological and molecular techniques for the diagnosis of symptomatic congenital human cytomegalovirus infection in neonates and infants.

PURPOSE: Human cytomegalovirus (HCMV) is the commonest pathogen causing congenital infection globally. The diagnosis of congenital infection is based either on viral isolation (in cell culture) or demonstration of HCMV DNA from the urine. Saliva is also being used as an alternative sample to urine for the same. The objective of this study was to compare the following assays-polymerase chain reaction (PCR) from urine, saliva and blood, serology (anti-HCMV IgM) and antigen detection (HCMV pp65 antigenaemia) for the diagnosis of congenital HCMV infection. MATERIALS AND METHODS: Urine and blood samples were collected from 31 infants (median age: 13 weeks) with suspected HCMV infection. For 18 infants, additional saliva samples were collected and all the above assays were compared. RESULTS: PCR for HCMV DNA from urine and anti-HCMV IgM were performed for all 31 infants. Of these, 22 (70.9%) were positive for both assays. In 18 (of the 22) infants positive by both assays, PCR for HCMV DNA from saliva was positive in all 18 (100%), PCR from blood in 7/18 (38.8%) and HCMV pp65 antigenaemia only in 1/18 (5.5%) of the infants. CONCLUSION: Detection of HCMV DNA in urine combined with anti-HCMV IgM are suitable assays to diagnose HCMV infection in infants. Both PCR from the blood and HCMV pp65 antigenaemia lack sensitivity in infants. Salivary PCR combines convenience with high sensitivity and can substitute PCR from urine, especially in the outpatient and field settings. To the best of our knowledge, this is the first study from India to evaluate salivary PCR for the diagnosis of congenital HCMV infection.

Effect of position of infant during phototherapy in management of hyperbilirubinemia in late preterm and term neonates: a randomized controlled trial.

OBJECTIVE: To evaluate the effect of supine position when compared with periodic change of position during phototherapy in late preterm and term neonates (35 to 42 weeks) with hyperbilirubinemia on the duration of phototherapy. STUDY DESIGN: We randomly allocated enrolled neonates with hyperbilirubinemia to either no change in position (supine group (SG); n=54) or two-hourly change of position from supine to prone and vice versa (turning group (TG); n=46). All the infants received single surface phototherapy by two dedicated compact fluorescent light units. Total serum bilirubin (TSB) was measured at the start of phototherapy and then every 12 ± 2 h until the end of phototherapy. Phototherapy was stopped when two values were below the cut-off for age and gestational age as per the American Academy of Pediatrics Subcommittee on Hyperbilirubinemia guidelines nomogram for the management of hyperbilirubinemia in infants >35 weeks of gestation. The primary outcome was duration of phototherapy and secondary outcome was rate of fall of bilirubin within the first 24 ± 2 h after the initiation of phototherapy. RESULT: Baseline characteristics including birth weight (g, 2752 ± 478 vs 2748 ± 416 P=0.96), gestation (week, 37.1 ± 1.2 vs 37.4 ± 1.3, P=0.26) were similar in the two groups. There was no difference in the duration of phototherapy between the SG (mean ± s.d., hour, 25.5 ± 8) and TG (mean ± s.d., hour, 24.8 ± 5), mean difference (95% confidence interval), hour, 0.7 (-2.03, 3.44, P=0.6). Rate of fall of bilirubin was also similar in both supine and turning groups with mean difference of -0.020 (95% confidence interval: -0.061, 0.021, P=0.34). CONCLUSION: Nursing babies in supine position when compared with periodic position change during phototherapy does not decrease the duration of phototherapy.

Does mesenchymal stem cell population in umbilical cord blood vary at different gestational periods?

OBJECTIVE: To identify and quantitatively determine Mesenchymal stem cells (MSCs) in the umbilical cord blood (UCB) of neonates born at different gestational periods. METHODS: UCB was collected at birth in neonates of three different gestational groups. The mononuclear cells (MNCs) were phenotypically analyzed by flow cytometer. RESULTS: The yield of total MNCs did not differ much with gestation; the average values were 22.6 ± 6.48 × 106 cells/ml. The MSCs were significantly higher in the lower gestation group. These were 0.0219 ± 0.012 %, 0.0044 ± 0.003 % and 0.0022 ± 0.003 % in 28 to 31 wk, 32 to 35 wk and >36 wk, respectively (P = 0.00). There was a significant inverse correlation between the gestational age and the presence of MSCs with a correlation co-efficient of -0.54 (P = 0.0001). CONCLUSIONS: The MSCs population was significantly higher in infants born at lesser gestation than those born at term gestation.

Transcutaneous bilirubinometry reduces the need for blood sampling in neonates with visible jaundice.

OBJECTIVES: We determined usefulness of transcutaneous bilirubinometry to decrease the need for blood sampling to assay serum total bilirubin (STB) in the management of jaundiced healthy Indian neonates. METHODS: Newborns, > or =35 weeks' gestation, with clinical evidence of jaundice were enrolled in an institutional approved randomized clinical trial. The severity of hyperbilirubinaemia was determined by two non-invasive methods: i) protocol-based visual assessment of bilirubin (VaB) and ii) transcutaneous bilirubin (TcB) determination (BiliCheck). By a random allocation, either method was used to decide the need for blood sampling, which was defined to be present if assessed STB by allocated method exceeded 80% of hour-specific threshold values for phototherapy (2004 AAP Guidelines). RESULTS: A total of 617 neonates were randomized to either TcB (n = 314) or VaB (n = 303) groups with comparable gestation, birth weight and postnatal age. Need for blood sampling to assay STB was 34% lower (95% CI: 10% to 51%) in the TcB group compared with VaB group (17.5% vs 26.4% assessments; risk difference: -8.9%, 95% CI: -2.4% to -15.4%; p = 0.008). CONCLUSION: Routine use of transcutaneous bilirubinometry compared with systematic visual assessment of bilirubin significantly reduced the need for blood sampling to assay STB in jaundiced term and late-preterm neonates. (ClinicalTrials.gov number, NCT00653874).

Does skin cleansing with chlorhexidine affect skin condition, temperature and colonization in hospitalized preterm low birth weight infants?: a randomized clinical trial.

OBJECTIVE: To examine if single skin cleansing with 0.25% chlorhexidine affects skin condition, temperature and bacterial colonization in stable preterm (28-36 weeks gestational age) low birth weight (1001-2000 g) infants admitted in a health facility. METHODS: Eligible infants were randomized within 3 h of birth into the following three groups: chlorhexidine, normal saline or no skin cleansing. Infants in the first two groups were wiped once with baby wipes containing either 0.25% chlorhexidine or saline. Skin condition, axillary temperature and skin colonization rates in the axilla and the groin were assessed at specified time intervals after intervention. RESULTS: In all, 60 infants were included in the study (20 in each group). Median skin condition scores at 72 and 168 h after the intervention were 2 and 2, respectively, in all three groups. At 30 min after skin cleansing, two infants each in the chlorhexidine and saline cleansing groups and none in the no cleansing group experienced cold stress (36-36.4 degrees C). There was, however, no difference in mean skin temperature of the groups (36.6 degrees C). At 24 h, skin colonization rates in the axilla were 22.2, 52.7, and 57.9%, respectively, in the chlorhexidine, saline and no cleansing groups (P=0.06); skin cleansing with chlorhexidine reduced the incidence of colonization by 62% compared with no cleansing (relative risk (RR): 0.38, 95% confidence interval (CI): 0.15, 0.98), but there was no significant reduction when compared with saline cleansing (RR: 0.42; 0.16-1.10). Axillary colonization rates at 72 h and colonization at the groin at 24 and 72 h were not significantly different across the three groups. CONCLUSION: Single skin cleansing with 0.25% chlorhexidine did not adversely affect skin condition or temperature in hospitalized preterm infants and reduced axillary-skin colonization at 24 h after the intervention. Trials are needed to evaluate the efficacy of such an intervention on the incidence of infections in preterm neonates.

Limb splinting for intravenous cannulae in neonates: a randomised controlled trial.

OBJECTIVE: To evaluate the efficacy of peripheral intravenous (IV) cannula site joint immobilisation by splint application on functional duration of peripheral IV cannula in neonates. DESIGN: Randomised controlled trial. SETTING: Neonatal intensive care unit of a tertiary care hospital. PARTICIPANTS: Neonates requiring continuous IV infusion for an expected duration of more than or equal to 72 hours. INTERVENTION: Eligible cannulations were randomised to either "splint" or "no-splint" group. In the splint group, a cardboard splint was used to immobilise the joint at peripheral IV cannula site. No attempt was made to immobilise the limb in the no-splint group. OUTCOME MEASURE: Functional duration of a peripheral IV cannula measured as interval from time of insertion to the development of predefined sign of removal (extravasation, blockage, inflammation). RESULTS: A total of 69 peripheral IV cannulations in 54 neonates were randomised to either the splint (n = 33) or no-splint group (n = 36). Both groups were comparable in birth weight, gestation, site of cannulation and nature of fluids administered. Mean functional duration of cannula was lesser in the splint group compared to the no-splint group (h; 23.5 (SD15.9) vs 26.9 (SD15.5), mean difference: -3.3 h, 95% CI -11.02 to 4.3 h) although the difference was not statistically significant (p = 0.38). Extravasation at cannula site was found be the commonest indication for cannula removal in both the groups (84% vs 76.5%). CONCLUSION: Joint immobilisation with splint at cannula site did not improve the functional duration of peripheral IV cannula.

Efficacy of two dose regimes of intravenous immunoglobulin in Rh hemolytic disease of newborn--a randomized controlled trial.

OBJECTIVE: To compare the effect of two dose regimes of IVIg (0.5 g/kg vs. 1g/kg given soon after birth) on duration of phototherapy in Rh-isoimmunized neonates 32 week and above gestation. DESIGN: Randomized controlled trial. SETTING: Tertiary care hospital. SUBJECTS: Rh positive blood group neonates of gestation 32 weeks and above born to Rh negative mothers having positive Direct Coombs test and without any major malformation. INTERVENTION: Intravenous immunoglobulin (IVIg) infusion over 2 h either 0.5 g/kg (low dose group, n=19) or 1.0 g/kg (high dose group, n=19). PRIMARY OUTCOME VARIABLE: Duration of phototherapy. RESULTS: The mean duration of phototherapy was 77.3+/-57.2 h in low dose group versus 55.4+/-49 h in high dose group (mean difference=21.9; 95% CI-13.1 to 56.9). There was no difference in need for exchange transfusion (21% in both the groups) and requirement of packed red blood cells transfusion (12 transfusions in both groups). The duration of hospital stay was similar [8.4+/-6.9 and 13.6+/-14.8 days, respectively (mean difference=-5.1; 95% CI-12.8 to 2.5)]. No adverse effects of IVIg administration were noted. CONCLUSION: Two regimens of IVIg (0.5 g/Kg or 1 g/Kg) had comparable effect on duration of phototherapy, duration of hospital stay and exchange transfusion requirement, in Rh isoimmunized neonates of gestation 32 weeks and above.

Cesarean section for suspected fetal distress, continuous fetal heart monitoring and decision to delivery time.

OBJECTIVE: To find out the efficacy of continuous fetal heart monitoring by analyzing the cases of cesarean section for nonreassuring fetal heart in labor, detected by cardiotocography (CTG) and correlating these cases with perinatal outcome. To evaluate whether a 30 minute decision to delivery (D-D) interval for emergency cesarean section influences perinatal outcome. METHODS: This was a prospective observational study of 217 patients who underwent cesarean section at > or = 36 weeks for non-reassuring fetal heart in labor detected by CTG. The maternal demographic profile, specific types of abnormal fetal heart rate tracing and the decision to delivery time interval were noted. The adverse immediate neonatal outcomes in terms of Apgar score <7 at 5 minutes, umbilical cord thornH <7.10, neonates requiring immediate ventilation and NICU admissions were recorded. The correlation between non-reassuring fetal heart, decision to delivery interval and neonatal outcome were analyzed. RESULTS: Out of 3148 patients delivered at > or = 36 weeks, 217 (6.8%) patients underwent cesarean section during labor primarily for non-reassuring fetal heart. The most common fetal heart abnormality was persistent bradycardia in 106 (48.8%) cases followed by late deceleration in 38 (17.5%) cases and decreased beat to beat variability in 17 (7.8%) cases. In 33 (15.2%) babies the 5 minutes Apgar score was <7 out of which 13 (5.9%) babies had cord thornH <7.10. Thirty three (15.2%) babies required NICU admission for suspected birth asphyxia. Rest 184 (84.7%) neonates were born healthy and cared for by mother. Regarding decision to delivery interval of < or =30 minutes versus >30 minutes, there was no significant difference in the incidence of Apgar score <7 at 5 minutes, cord pH <7.10 and new born babies requiring immediate ventilation. But the need for admission to NICU in the group of D-D interval < or = 30 minutes was significantly higher compared to the other group where D-D interval was >30 minutes. CONCLUSION: Non-reassuring fetal heart rate detected by CTG did not correlate well with adverse neonatal outcome. There was no significant difference in immediate adverse neonatal outcome whether the D-D time interval was < or = 30 minutes or >30 minutes; contrary to this, NICU admission for suspected birth asphyxia in

Vitamin K1 versus vitamin K3 for prevention of subclinical vitamin deficiency: a randomized controlled trial.

OBJECTIVE: To compare efficacy of intramuscular phytomenadione (fat soluble vitamin K or vitamin K1) with menadione (water soluble vitamin K or vitamin K3) in prevention of subclinical vitamin K deficiency. DESIGN: A doubleblind randomized controlled trial. SETTINGS: Tertiary care hospital. METHODS: Healthy term neonates were randomized to receive 1 mg of either phytomenadione (Group I, n = 85) or menadione (Group II, n = 85) intramuscularly within 2 hours of birth. PIVKA-II, a sensitive and specific marker of vitamin K deficiency was measured by ELISA method (Diagnostica Stago, France). Plasma level > 2 ng/mL was labeled as detectable PIVKA-II. RESULTS: Birth weight (2914 +/- 318 vs 2958 +/- 312 g), gestation (38.4 +/- 1.2 vs 38.4 +/- 1.0 wk) and other baseline variables were comparable between the two groups. 48.2% (41/85) neonates in Group I and 44.7%(38/85) neonates in Group II had detectable PIVKAII levels ([Relative Risk (95% confidence interval): 1.1 (0.8-1.5); P = 0.76]). Median PIVKA-II levels in Group I and Group II were 1.99 ng/mL and 1.97 ng/mL respectively (P = 0.26). At 72 +/- 12 h of age, mean packed cell volume and mean serum bilirubin levels were comparable in the two groups. CONCLUSION: Comparable PIVKAII detection rate and PIVKAII levels in neonates receiving phytomenadione or menadione indicate their similar efficacy in prevention of vitamin K deficiency. However, high PIVKAII detection rate observed with both preparations indicates recent vitamin K deficiency and may be due to either inadequate dose of vitamin K or persistence of PIVKAII of fetal origin.

Clinicoepidemiological profile and predictors of severe illness in young infants (< 60 days) reporting to a hospital in North India.

OBJECTIVES: To describe the clinical and epidemiological profile of young infants reporting to a hospital and assess previously proposed simple clinical signs for their value in enabling health workers to detect young infants with severe illness warranting hospital admission. METHODS: Observational study of infants less than 2 months of age presenting consecutively to a large public hospital in South Delhi who were evaluated by a health worker (nurse), on a standardized list of signs and symptoms, and the ability of these were evaluated against the need for hospital admission which was assessed by an independent pediatrician. RESULTS: Of the 1624 young infants triaged, 878 were enrolled into the study. Of these 100 (11%) were below 7 days of age, for whom the common reasons for seeking care were jaundice (52%), not feeding well (6%) and fever (5%). The remaining 778 (89%) were 7-59 days of age with respiratory symptoms as the main presenting complaints (29.1%). The primary clinical diagnoses in infants with serious illness needing admission to hospital in the age group <7 days (n = 66) were hyperbilirubinemia (56%) and sepsis (21%). In those between 7-27 days of age (n = 60), primary diagnoses were sepsis (27%), pneumonia (13%), diarrhea, dysentery or dehydration (10%), while in the age group 28-59 days of age (n = 47) pneumonia (40%), sepsis (19%) and diarrhea or dehydration (13%) were the common primary diagnoses. Signs that had at least a prevalence of 5% and were strong predictors for all the age categories studied were history of difficult feeding (OR 6.8 for 0-6 days, 15.1 for 2-27 days and 6.2 for 28-59 days age groups), not feeding well on observation (OR 13.7, 27.6 and 20.9 respectively for the 3 age groups), temperature > 37.5C (OR 21.8, 14.6 and 30.0 respectively for the 3 age groups) and respiratory rate > 60 per minute (OR 6.8, 15.1 and 21.0 respectively for the 3 age groups). Additional strong predictors with > 5% prevalence were history of convulsions (OR 7.9, only in 0-6 day age group), lethargy (OR 26.1, only in 7-27 day age group), and history of diarrhea (OR 3.0 for 2-27 days and 2.2 for 28-59 days age groups). CONCLUSIONS: Simple clinical signs are useful in hands of health worker for identifying neonates with serious illness warranting hospital admission. These will be of use in the further development of clinical algorithms for the national integrated management of childhood illnesses.